Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.

Friday, August 03, 2007

Confessional

There's something irresistibly horrifying about doing an amputation. I did several during training, and a few in practice, before eventually turning such cases over to people who did it more. In a way, it's a microcosm of the perversity and beauty of surgery; of the screaming contradiction that one must somehow accept to be a surgeon. Removing a limb is so many things: failure, tragedy, cataclysm, life-saver, life-ruiner. Gratifying.

Stark and sudden, an above-knee amputation done in the "guillotine" fashion for infection is shocking. But, if you're a surgeon, you can -- maybe you must -- find pleasure in it; and I don't mean some poetic sense of helping one's fellow man. I mean in the actual act of doing it. Which is why I say it's a microcosm. Some things we do are terrible. And yet, within walled-off portions of the mind, divorced from the suffering of the patient, there's a place to go wherein satisfaction comes from the the work itself; the physicality, the artistry, even the transgressive brutality.

The foot, dying, has been wrapped in towels and covered in a sterile plastic bag. The leg, painted in iodine, protruding through a paper drape with a rubberized hole in it, is all you can see of the patient. With the knee bent, you place the covered foot on the table, and it holds itself in place. Holding in your hand the rough handle of a huge amputation knife, you reach as far as you can under the thigh and bend your arm back over the top toward yourself, curling the knife blade around and under the thigh as much as possible. Can you see what's going to happen? You're going to uncurl your hand and arm, drawing the knife, as deeply as you can, completely around the thigh; slashing -- if it works -- in a single circular motion all the way down to and around the femur. If there were normal circulation, you probably wouldn't be doing this; so there's often not much bleeding. Still, you need to be aware of the femoral artery and be ready to clamp it quickly. Maybe you've placed a tourniquet of some sort above; or maybe you have a strong and big-gripped assistant who's squeezing the leg between both hands. In any case, once the bone is visible around its entire circumference, you reach for the gigly saw -- that's what's pictured at the top of this post.

And, while someone holds the leg down, you place the wire under the femur, grab the handles between the middle and ring fingers of each hand, and stretch the saw nearly straight. Back and forth, fast as you can, making the toothed snake rise through the bone, which it does with surprising ease. It's a whirring sound, more than grinding -- high-pitched, err err err err. White until you get to the marrow, the fragments coming off are like gruel. And then the wire springs up with a flap and a splatter as it rises out the top. Start to finish, it's been only a couple of minutes. (Somewhere I read of the fastest such amputation, done in a few seconds, including the removing of a couple of the assistant's fingers.)

It's awkward lifting the leg off the table and handing it away. The balance point is hard to find. There's an awareness of mutual discomfort in this act -- in the giving and the receiving. (A gallbladder plops into a pan, free of emotion. Handing one person the leg of another: that's an exchange for which there are no words.) It's a relief to return gaze to the stump: concentric and clean. White bone, red muscle, brown skin. The anatomy is there, on end: hamstrings, quadriceps, neurovascular bundles. It's not a commonly seen slice.

Before the operation, there's been pain -- physical and emotional. There've been sad talks, bargaining. Nothing to feel good about, for anyone. After, there's the stark realization, the encouraging words that ring hollow. The relief -- mine -- of turning much of it over to rehab specialists, prosthetists. But there, for that few moments in the operating room, there's a separate, private, and possibly unspeakable pleasure. (And I must say the same can be said about other amputations I did throughout my career, hundreds and hundreds of times, as a breast cancer surgeon.) The dissociative and dramatic doing. The fact that, for an instant, I can remove from my consciousness the horror and find enjoyment in my craft, can see beauty even here -- that's something almost too terrible to admit, even now.

36 comments:

Well, your text gave me the shivers, but I'm extremely happy to learn about what the job of a surgeon is. (In Grey's Anatomy, they obviously have only sentimental problems 90% of the time and therefore don't have time for actual surgeries, let alone blog about them)

Good post. The first surgery I ever scrubbed on as a 3rd yr med student was the amputation of a gangrenous foot. You are so correct in how hard it is to "hand" it over and to "receive" it. Yet it is pleasing to see the limb then heal (yes, I know it is no longer whole, but it is no longer "killing" the individual either). I found (find) it even more difficult to have to amputate fingers or an entire hand due to infection or injury. I am ever grateful for the orthotists who make "new" limbs when we can't "save" them or "find" a way to make a new one (great toes for thumbs).

Man, I hate giving anesthetics for amputations; I used to keep a cd-player/headphone combo in my locker so I could mask the saw sound for patients with spinals and sedation, when we thought that regional decreased the incidence of phantom limb pain. Now I just use general anesthesia.

Ditto on the general anesthesia...Just wanted to say Dr. Schwab how I appreciate the compassion in your writing and admire your expertise with both pen and scalpel. Like many other anesthesiologists who read your blog, I imagine, I would be so happy to work with a surgeon like you...

Good grief, Doc...this was not a pleasant thing to read only a few months after spending over a week in hospital with a nasty foot abscess, with a roommate who was having her foot amputated, no less! What is it with this penchant surgeons have for the graphic stuff that tends to scare the hell out of people? Fortunately I managed to leave with all of my appendages still intact, but the whole idea gave even this normally fairly calm and research-oriented patient a practical coronary! Still enjoy your blog, though...even if it did make me sit up and take unusual notice!

I've never seen an amputation being done, though I recall as a med student rotating in pathology have a leg arrive in a bag as a specimen -- these are pretty uninteresting to pathologists, it seems.

I've also seen many an outcome of amputation, since I take part in the Amputee Clinic at our Rehab Unit. As you are trying to care for the amputee, looking forward to future fitting for a prosthesis, you begin to appreciate a beautifully done amputation, with care taken not just to oppose edges of skin but also to think about rounding, smoothing the underlying end of the bone, the padding underneath with muscle and other soft tissues so as to protect the skin. And for many, I'd say most, life goes on after the amputation, a bit differently, but all in all not so badly.

Greg: I didn't go into those details, but you're exactly right: doing those things that can make the stump heal properly and be right for a prosthesis make for a sense of satisfaction. In the case of the guillotine amputation, there's usually a second operation to revise and prepare. But it's a good example of that disconnect that goes along with much of surgery.

I fear ampution of my leg or legs second only to paralysis. I cannot begin to imagine how an amputee deals with the loss. It is one of those procedures that reminds me of just how fortunate I really am. I NEVER complain about having to walk too far or taking the stairs.

P.S. I liked the post you deleted better. Will it come back new and revised? Surely you were not offended by comments?

Sid, leg amputations play an important role in the lore of anesthesia history. Prior to ether, leg amputations were performed commonly, with surgeons being respected for their speed (less than 2 minutes) and sang-froid (not distracted by the screaming) Ligatures hanging from button holes of blood-stiffened operating coats, etc. At Wisconsin, in the Anesthesia library, we had the bell mounted that summoned the "brutes" whose job it was to restrain the hapless patient...

your second paragraph about the terrible and satisfying nature of an amputation was spot on. i love amputations, yet it does not deter from how terrible they are. the worst i did was an arm. that to me really takes from the humanity of the patient. a leg is simply a leg but an arm is interwoven with the humanity of ther patient

Harry: good question. In fact, I'd thought about using that example, since I've done several harvest operations, as well. I also half-wrote it based on mastectomy. The fact is there is much in surgery in which one most separate the craft from the tragedy.

Great post. The horror of amputations didn't hit me until the chief year of residency. As a junior resident, I loved when I saw a BKA on the schedule; it meant I was actually going to operate. By the time I was ready to move on to an attending position, the sound of saw churning through bone sickened me. Granted, there is an art to it. Creating a perfect muscular flap that fits precisely, like a puzzle, without dog ears is quite satisfying.

I would hesitate to compare extremity amputation to mastectomy, however. A woman who needs a mastectomy is a victim of bad luck, genetics, and the vicissitudes of fate. A person who needs an amputation (other than traumatic amps) is someone who has repeatedly failed to heed medical advice. At the county hospital where I trained, I saw the same patients come in year after year. They have uncontrolled hypertension. They smoke. Their diabetes is uncontrolled. You read through their chart and they've had fem-pop bypass, re-do fem-pop, and then a fem-distal. First, a toe is amputated. And then wet gangrene sets in and you have to take the forefoot. And that stump doesn't heel so you have to do guillotine chop job to halt the sepsis. A few weeks later that gets revised to a formal below knee amp. Every time they come to the hospital, you note that blood sugar readings are always over 200. They forgot to fill ther blood pressure medicine scripts. And, frequently, they STILL SMOKE!!!!!. There's a bit of personal culpability in leg amputations.

Harvest operations are extremely different. For one thing, you're taking organs out of a corpse, for all intents and purposes. The man with an above knee amputation has to live with your handiwork.

B. Surgeon: the similarity among them to which I refer is the extent to which one is able to ignore the horrible reality while carrying out the operation, focusing on -- and even enjoying -- the craft in the face of tragedy.

Harvest amputations have a rather different meaning out here on the prairie this time of year. The radio reminds the guys on the machinery to take ice and zip-loc bags with them to the field in case they accidently lop off fingers. Those huge bale rollers, if they catch a finger or sleeve, will yank arms right out of their sockets. One man working alone lost both arms but was able to drive himself home with his feet. He said the worst part was getting the key to his pickup into the ignition and that everyone should remember to leave the key already there. The next worst part was trying to hold off shock until he could get to his wife.

Ranchers would recognize that saw. If a calf can't be delivered because of wrong presentation or too small a cow pelvis, the calf is sometimes sawn up in utero and removed in pieces. That avoids a Caesarean.

The other day the newspaper had a photo of Bush with two veterans, one just a single amputee and the other double. They had "Stars Wars" legs -- no attempt to make them look human but they work good while moving. Standing still, it's necessary to get a grip on a prop, so they were both gripping Bush who looked a little stricken. The veterans were big, fit, tan men from the hips up. Bush, not so much -- from the soles up.

I sawed a big limb off my major yard tree the other day and had feelings faintly resembling what you describe here. No chain saw, just my bow saw. Had to be done as it was dead. Feeling of accomplishment once it was on the ground, but the question of what to do with it. There's something person-like in a tree, as well-illustraed in Lord of the Rings.

Didn't think I was squeamish but think I might be if I saw an extremity separate from the body. Not toes - I've carried them but definitely the bigger parts would be unnerving. The internal organs removed wouldn't bother me but something about those extremities not being attached -not easy to think about. It was difficult reading about your cutting through the leg.

I don't know how the 911 workers did it down at ground zero. Must've been a lot of PTSD.

My mother had her leg amputated in 1983 due to cancer she was 25, with three young children. The guys from MD Anderson and the surgical team that consisted of seven of the top international surgeons deliberated for 15hours what the best course of actions was for her in order to perhaps extend her life. She asn my father drove to South Texas to go to the beach we kids were told and mom came back without a leg.

But it gave us two more years with her. She died of lung cancer in 85 I was seven. And for the two years I am thankful.

my brother in law is having his left leg removed below the knee next week. he and my sister have a 6 year old daughter. he drove dump trucks and plow trucks in the winter, now he's losing his clutch leg, and most probably his driver's license (cdl). she has 2 teenagers from a previous union, and their daughter was born a premie, and has some developmental issues. now she will be the only bread winner for the forseeable future. funny hting is i wasn't even looking up amputations, i was just browsing reddit, and came accross this link. at first, when reading your blog, i was confronted by certain aspects of your description, words like pleasure, sound descriptions... but who am i to say, how i might deal with such a workday, where i had to perform such duties. we all have unpleasant days, and face uncomfortable situations. i paint walls, and sometimes old ladies make it painfully obvious i have been hired in hopes of some illicit sexual fantasies being realised... oh well, thank you for being who you are, all you people of the medical community. thank you for studying, and successfuly completing your studies, and dedicating your lives, to such unpleasantries. god, where would humanity be without you? thank you. peace

Was a surgeon at the 93rd Hospital in Vietnam and amputated more limbs than I can recount. No problem until returning to civilian practice and the multitude of vascular amputations. From the beginning of my return would do an amputation, finish and then go to the locker room and vomit. My staff protected me for many years. Martin

Was a surgeon at the 93rd Hospital in Vietnam and amputated more limbs than I can recount. No problem until returning to civilian practice and the multitude of vascular amputations. From the beginning of my return would do an amputation, finish and then go to the locker room and vomit. My staff protected me for many years.

Found your blog through a diary on DailyKos, and started reading a couple of days ago. Very thoughtfully written, and thought provoking. I've almost written comments on several entries, but this one was personal, as I was on the other side.

The saw noise woke me up, twice. I saw the sheet between me and the source of the sound, one horrified attendent noticing me looking, but I felt relief to know it was happening. The last memory before that was telling the ER nurses beside me I was dying, one saying I wasn't, at which I look at my blood pressure monitor, and responded, "53 over 37, that's dying." When the car spun and ground my ankle and foot against the lamppost, a high pitched whine rang in my ears. Time stopped long enough for me to look down to see car metal touching lamp metal through skin and bone, a man in a red pickup staring at the redlight, to look up the sidewalk and actually feel relief no one else was there to get hit as all began moving again and the car careened away. (My first thought: "Here's something else to deal with.") The pain was intense; I think perhaps 3-4" held the remains of my ankle and foot on. Everyone has been burned; the pain builds and reaches a plateau and stays there a while. This was the same, except multiplied beyond description and there was no plateau. I managed to fall backwards, holding my leg up, scream for an ambulance, got one of the stunned men who gathered around me to give me a DAMN tie for a tourniquet ("Yes, I know it will stop my circulation!"), and have another call my mom to tell her I had a broken leg so she wouldn't panic but would go to the hospital (where she could panic safely). The other horrible sensation was my heart trying to beat normally. I feel it contract - whoosh, and then strain to pull blood back in. I got 9-11 units, I don't remember; a friend told me it was equal to all the blood in my body. (I do wish they'd asked before the Benedryl was injected for side effects - I'd have told themI'm allergic but instead shook and couldn't close my eyes for 3 hours, like speed.) I love my orthopaedist (as much as my oncologist, but that's a story from 10 years, now 20, earlier - level 4 melanoma). It took 2 years for all the surgeries, 5 initially and 3 the following year for graft clean-up and a bone spur. I still have pain, though low-level usually, like a small electrical charge. The bad ones come rarely now, which I equate to being plugged into a transformer, zinging from the tip of my stump to all parts of my body. I beat my leg with my fist and it helps a bit. If it last longer than 2-3 hours I hunt friends with pain med prescriptions. It is nerve damage NOT phantom pain.

I know I've written too much, and I could write more but then I should just start my own blog (The Patient?). I noticed how many comments are from medical professionals and figured a patient's view might interest some. Thank you for your indulgence, and a wonderful blog.

I realize this is much, much too late for any sort of real conversation, but reading people say how horrified they are at the notion of losing a leg always makes me sad. My mother effectively has an AK (birth defect)and she gets on fine. Chased three children around, worked retail (8 hours on your feet-not easy for those of us with all our limbs), bicycles, teaches disabled skiing, hikes, swims, and generally enjoys life. It's all about attitude. And surgeons who take into consideration padding the weight-bearing portion of the stump.

Also, "Star Wars" prosthetics are such an improvement from the old "door hinge." I remember my mother demonstrating - graffically, with twigs- why children's hands NEVER EVER go near the knee.

I'm late to find your post. Laughably so, but it still hits home hard. Thank you for writing it. I have had several major surgeries (no amputations yet, thankfully) and have had the greatest difficulty understanding the position of a surgeon. On the outside, many seem brash, overbearing, laden with testosterone, and a part of me wonders if it isn't some coping mechanism. The remainder are diminutive by comparison, clean, fastidious, and always with a slight smile, as if they're enjoying some personal secret. In both scenarios, I can't imagine any surgeon being so close-minded as to be unaware of the incredible burden of responsibility they bear. Yet they act like it, compartmentalizing it somehow.

In the case of an amputation, I cannot begin to fathom difficulties involved with sleeping at night. On the one hand, a surgeon is doing it because a person may die if it's not done. On the other hand (if it still remains), one cannot ignore the fact that one is cutting off an essential piece of another human being. Prosthetics may be involved, but it's not the same. A person has been irrevocably altered, lessened, and I suspect in cases where amputations occur following car accidents or other such emergencies the patient must experience feelings of intense anger, violation, and betrayal. Yet a surgeon would not be able to carry out so complicated and delicate an art as theirs if they didn't find some beauty in it, some perverse interplay between horror and joy.

Is that why the patient is always covered? Is that why you can never look them in the face, take in who they are? Because the gravitas of the situation would freeze you? Because your knife would be stayed if you were struck by the profound realization that the person you're working on, the one who draws breath beneath your blade, will never be the same once your work is done? How do you cope with that?

And handing off the leg. How can you? You're throwing away a part of a human being. Something once and still needed, now bound for incineration. Do you need to get the patient's permission first for validation? I sure would.

Of course, unless it's some sort of emergency and an unconscious patient, surgeons interact very closely with patients prior to operating. Some more effectively and empathetically than others, no doubt; but you can't avoid it entirely.

The covering of the patient, which occurs after those interactions and obtaining consent, is mostly for sterility reasons. I've let awake patients watch some of their operation using a mirror. And I nearly always talked to them while I was operating; that's part of the fun of a local: making it painless and lessening their anxiety.

Thanks very much for your quick reply. One other thing did occur to me: Have you ever had to perform an amputation following an emergency? If so, in what way did it differ than your usual approach with a patient?

Read my book, starting on page 125. There's a story in there of a kid who developed "flesh-eating disease" (necrotizing fasciitis) and who refused to have his leg amputated. Age twenty-something. Said he'd rather die, which he would have...

Trauma, and any other sort of severe surgical emergency, changes everything: there may be no time to obtain "informed consent," and the patient may be in no position to give it. Sometimes you just have to do what you have to do, and be willing to take the consequences.

It sounds like you're saying you carried out an amputation against the consent of a patient by citing an emergency in which informed consent could not be obtained... I'm sorry, but I'm not sure I want to read something like that.

Your style of prose is excellent. But, considering a kid had his leg cut off, I'm on the fence about that. What's the ethics of a situation like that, where a patient has refused treatment? How do you know what you're doing is right?

About Me

Boring, Unoriginal, but Important Disclaimer:

What I say here is as true as I can make it, based on my experience as a surgeon. Still, in no way is it intended as specific medical advice for any condition. For that, you need to consult your own doctors, who actually know you. I hope you'll find things of interest and amusement here; maybe useful information. But please, please, PLEASE understand: this blog ought not be used in any way to provide the reader with ideas about diagnosis or treatment of any symptoms or disease. Also, as you'd expect, when I describe patients, I've changed many personal details: age, sex, occupation -- enough to make them into no one you might actually know. Thanks, and enjoy the blog.